2016 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Cross Medicare Advantage Choice Plus (PPO) (H0107-001-0) Benefit Details | ||||||
This plan is available in Gallatin County, MT Monthly Premium: $33.00 Rx Deductible: $0 Initial Coverage Limit: $3,310 Click on a letter below to view the Blue Cross Medicare Advantage Choice Plus (PPO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
This plan does not have an Initial Deductible: | n/a | n/a | n/a | n/a | n/a | n/a |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $0.00 | $5.00 | n/a | $0.00 | $15.00 | $15.00 |
Tier 2: Generic: | $6.00 | $11.00 | n/a | $18.00 | $33.00 | $33.00 |
Tier 3: Preferred Brand: | $39.00 | $44.00 | n/a | $117.00 | $132.00 | $132.00 |
Tier 4: Non-Preferred Brand: | $85.00 | $95.00 | n/a | $255.00 | $285.00 | $285.00 |
Tier 5: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing 42% Generic and 55% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $0.00(A) | $5.00(A) | n/a | $0.00(A) | $15.00(A) | $15.00(A) |
Tier 2: Generic: | $6.00(A) | $11.00(A) | n/a | $18.00(A) | $33.00(A) | $33.00(A) |
All Formulary Generic Drugs: | 58% | 58% | 58% | 58% | 58% | 58% |
All Formulary Brand-Name Drugs: | 45% | 45% | 45% | 45% | 45% | 45% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.95 | The greater of 5% or $2.95 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $7.40 | The greater of 5% or $7.40 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the Blue Cross Medicare Advantage Choice Plus (PPO) 2016 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 |